Family Medicine: Day 3, 4

This is fun. A day on Family Medicine is like a day spent taking practice exams - each patient is so very different, and you have no idea what to expect when you walk into a patient's room. It's like a big quiz - and, since it's the end of third year, I am having a lot of fun remembering all the things I've learned in the past 3 years. I'll admit I'm astonished by the amount of stuff I have remembered; when you continuously work with specialists, you feel like you know nothing because they know so much about their particular field.

I had a young girl with abdominal pain today, and I figured out she was suffering from acute cholecystitis (not a difficult diagnosis, but I was definitely expecting her to have viral gastroenteritis before I walked in the room). So I put together the appropriate work up and treatment. When the family doctor went into the room, she didn't even have to ask the patient any questions, she went straight into explaining diagnosis and the tests we were ordering. It felt pretty great to know that I did this one on my own, from start to finish. I know I've done this before, and I've helped in the care for my patients in the past year, but today I actually felt confident enough to have done it on my own - which is a big deal. I actually feel like I am directly responsible for the patients I see, so I'm really integrating everything I know so I can treat them in the best way that I can. I feel like I'm one step closer to becoming a doctor...

I have also been caring for a man with Stage IV Lung Cancer who is in the hospital with low white cell counts and an infection. I sat in his room talking with him about his story for over an hour yesterday; I learned so much and we had some laughs. I can't help but love the oncology patients...


On a side note:
Lucky me - I have a FOUR DAY WEEKEND!!!!!!!! :) :) :)

Family Medicine: Day 1, 2

For my Family Medicine rotation, I am working at a rural hospital about an hour away from my apartment (and about a half hour away from my mom & dad's house).

 I love working in the rural hospitals for a few selfish reasons:

1. I'm encouraged to do stuff. I'll be doing proper doctor stuff for the next five weeks, including providing a differential diagnosis, selecting the most likely diagnosis, offering a treatment plan, and determining appropriate follow-up testing and appointments. I will also be doing loads of pap smears, wart removals, and other procedures that family doctors routinely do.
2. Free food. All the time. And it's decent food.
3. Patients mistake me for a real doctor because I wear a white coat. They don't even realize it's a short one! They just see white and immediately warm up to me.
4. Pharmacy reps are allowed on the hospital grounds. Which means more free food, and sometimes I also get fun little demonstration kits! I have one in my apartment which demonstrates how to properly insert a copper IUD - it sure makes for a good conversation piece!
5. The hours are pretty great. I work like an attending, not like a dog resident.
6. There are literally no pretentious doctors around. They don't get paid just for being smart, they get paid for being an effective (and likable) doctor. So they tend to be a lot of fun to be around.
7. Free food. Like, breakfast/lunch/dinner. I cannot stress this enough!

The physician I'm with for the next 5 weeks also has 6 women who are due to deliver sometime in the next 2 weeks. That means this girl will get to catch some babies! Beyond excited!!!!

The Things We Find in Our Patient's Ears

Going through 10 hours of orientation to the five-week Family Medicine Clerkship today reminded me of a patient I saw while I was on Peds...

She was about 12, and she had come in for her annual physical. Being the med student, I was the first of three people on the medical team to see her. After a clear H&P, I started on her physical exam. I began by looking into her ears...but when I peered down her left auditory canal, all I could see was fuzz. "Weird," I thought, "I don't really know what an ear drum is supposed to look like, but something tells me its not supposed to be fuzzy..." So I fetched the resident, who noticed something strange as well. After looking in her ear, she left the room, grabbed a long pair of tweezers and a flashlight, and returned. After fishing in her ear to retrieve the fuzzy mass, I pulled out a massive, waxy Q-tip head.

The girl didn't even know anything was in there.

I wonder what treasures I will discover in the next 5 weeks on Family Medicine! ;)

Radiation Oncology: Day 17, 18

The final two days of Rad-Onc have been wonderful. The patient who I have been following since my first week in clinic (with the large Head & Neck tumor) is now receiving treatments. I was able to go through each step of his care with the team, from initial referral and H&P, to contacting fellow physicians to review his plan, to his case presentation at our oncology team meeting, to his CT scan and radiation planning, to his mask fitting, to his simulation, and finally to his first day of treatment. It has been incredibly fulfilling to be able to follow a patient through the process of treatment; often during our third year, we take care of patients for a short while and they are lost to follow up, so we never know how effective our treatment was or how the patient is generally feeling (I love to know how my patients continue to do so this is a frustration for me). To be able to follow a patient from beginning to "middle" is very rewarding. I will be checking in with him as often as I am able to so that I may see how he responds to our treatment. With his current treatment plan, he does have up to a 50% chance of survival. I'd really like to be with him along the way to his cure.

Yesterday, I presented a lecture on chemotherapeutic agents and other modalities which enhance the effects of radiation. It was a really interesting area for me to research, and I have to say that I learned a LOT about a few chemotherapeutic drugs, especially in regards to their effects on radiation. Putting together the presentation was actually a lot of fun, but the whole presenting it and explaining it in simple terms was a bit more difficult!

The Powerpoint for My Presentation:

Chemotherapy & Radiation (2)

I have been so incredibly happy for the past 5 weeks; Maybe it has something to do with the sunshine and warmer weather, maybe it has to do with increased endorphins from working out more often, or maybe - just maybe - it's because I am working with the patients I've been made for. All I know is that I look forward to working every day and I come home from work feeling like I truly make a difference. I can't even explain how much I enjoy this...


On Tuesday, as a gift for my last full day in the clinic, the staff gave me two tickets to watch a baseball game in town. So, after we both finished work, Mike & I went downtown on Tuesday night to watch the game. After about a half hour of basking in the sunlight/relaxing/talking/watching the game, we ran into one of our friends, who invited us to his company's clubhouse for dinner and drinks. We ended up talking and meeting new people (there were several English men that Mike met, so he was happy chatting away about football and their shared English-ness all night while I mingled with new friends); All I know about the second half of the game is that we won! :)

Radiation Oncology: Day 16

Today was the day in the clinic where we check in with each of the patients who are currently undergoing radiation therapy. The main complaints are:

• Dysphagia and Mucositis - difficulty swallowing, ulcers, and dry mouths with thick saliva (in head and neck cancers).
• Shooting pains (in breast cancers - likely resulting from surgery and the impaired regeneration of nerve fibers).
• Redness, blistering, and pain on the skin overlying the treatment field (axilla for breast cancers, intergluteal clefts for rectal/anal cancers).

For the palliative patients, we find that most find real relief from pain after about 5-10 treatments. The response to radiation is so quick; it is always interesting to watch large head and neck tumors start to shrink away during the course of their radiation treatment. 

I also saw a patient who had a skin-reaction to the chemotherapeutic drug, Erbitux (Cetuximab), which is a monoclonal antibody of epidermal growth factor receptors, used most often in the treatment of colorectal cancer as well as head and neck cancers. Cetuximab works by binding to the epidermal growth factor receptor  and turns off the uncontrolled growth in cancers with EGFR mutations. Seeing as I want to become a medical oncologist, it's kind of nice to get to learn a bit about medical oncology whilst on this radiation oncology rotation!

This is really an exciting field. I love these patients, I love the staff, and I love being able to help those who are suffering from cancer. (I know, I'm starting to sound like a broken record - what can I say? I'm living my dream!!!!)

Radiation Oncology: Day 14, 15

A Few Short Stories:

1. Last night, I went to my very first pharmaceutical rep dinner party. It was phenomenal. Ethical discrepancies aside, I enjoyed an evening filled with enjoyable learning. First of all, we went to this high-class, top-end restaurant (where the average cost of one-person dining is well above $100), and the reps obviously paid for our meals. We had these delicious starters of scallops and crab cakes and mushrooms with cheese on bread and gorgeous salads and homemade bread and butter. The entire time we were at the presentation, they served us free drink as well - and only served top shelf liquors (not that I'd know, but the dirty martinis had some phenomenal queen olives and the Riesling was top notch). The meal was a choice between filet mignon, seared tuna, or chicken breast with smashed red skin potatoes and fresh asparagus. And the desert was a huge portion of either carrot or chocolate cake, already put into a to-go container (no way could any one eat the amount of food we were served in one sitting). So, food and drink was delicious. Got it. It was a beautiful venue. Okay. But why we were there was the best part of the night - the studies that were presented were so interesting. I couldn't get enough. Seriously. This thing they were "selling" seems to have a lot of potential in providing life-saving and cost-effective care to oncology patients. I was on the edge of my seat as I listened to the implications that this thing had. Seriously, I left the restaurant feeling on top of the world - I had this "a-ha" moment where it dawned on me that I am precisely where I am supposed to be right now, and I have discovered what I am meant to do with my life and it is exactly what I was put on earth to do. Not that the grey goose had anything to do with it... ;)
  * On a side note, to calm my ethical disturbance with this "free" evening, I am donating what I would have spent on the night to our local branch of the American Cancer Society.

2. After putting off scheduling an appointment with my PCP for an infection that I've been trying to fight off, I finally spoke with him today.
  MD: So, how long have you been feeling these symptoms?
  Me: Since last Tuesday.
  MD: Last Tuesday...like, as in 3 days ago?
  Me: No, as in 10 days ago.
  MD: So why see me today? Why not push it off longer? Why have you come in to see me already?
  Me: Oh, (that's a strange way to ask me, but) it's just gotten pretty awful since yesterday, so I thought I'd better just come in to see you.
  MD: Ok. You just don't seem too worried about it...
  Me: I guess I'm not real concerned, I'd just like to feel a bit better.
  MD: ...are you from a farm?
  Me: Erm, eh, yeah, yes, I was raised on a farm...(confused look on my face as I try to figure out why in the world had he asked me that as part of my HPI)
  MD: Oh! Ha!Ha!
  Me: ...why?
  MD: It's been in my experience that people from a farm act the same; if they feel well enough to be able to get done what they need to get done, to be able to work, then they don't think they're sick enough to see the doctor.
  Me: Yeah! That's exactly how my family is, that's how I am. That's crazy how you've got that figured out.
  MD: Well, my parents were farmers, and I practiced in a rural setting for many years, so I've had a lot of experience.

...hmm...so now I see why Mike has been so upset with me for not being seen earlier! I just don't want to ever be diagnosed with "med school-itis" or the "I-think-I-have-this-rare-disease-that-I-just-read-about" syndrome. Those are some scary things! ;)

3. This week during clinic, I overheard one of the Physicists interviewing a candidate who was applying for medical school. He put up an Xray of a woman's left thorax and asked the potential student what she thought about it, then proceeded to ask a whole bunch of physics and chemistry questions regarding how xrays are taken, differences between imaging techniques, how ionizing radiation works, etc. To be fair to her, she did pretty well, but she just sounded like an overly-confident know-it-all. For the questions which she clearly didn't have an answer (and no one would expect her to - they were trick questions), she made up some stuff and wiggled around giving a real answer rather than just admitting that she doesn't know. I couldn't help but think of the reason she was interviewing as a late-entry candidate might be because no other school liked her over-confidence, either. It's a shame, she really was smart. But no one likes a pretty smart doctor who doesn't know enough to know what she doesn't know.

I came to realize that I was in her shoes not so long ago, albeit not as a late applicant. Unlike her, I had just a few general medical knowledge questions, and most of my interviews were spent in ethical scenarios and conversations so that the interviewer could get to know me. I can't believe how much I've changed since my medical school interview 4 years ago. I've really grown up, but I still hope that am that same polite and compassionate girl I was when I was accepted into med school. I sure try to be.

Radiation Oncology: Day 13

So I realized a few things today...

• This calender has been up, beside my computer, on the month of April (and its now May 9th). Not only that, but it's from 2011. I couldn't be bothered to  never got around to buying a new one. And now, what's the point? It's not like I'm actually home long enough to be bothered by it! Which is totally not like me, I am normally SO OCD...

• Marley has had so much energy lately, but I haven't made it out to the park for a long walk with her in over a week. Poor dog. Don't worry, she gets me back by waking me up several times during the night to lick my nose...ah, the simple joys in life!

• We've resigned our lease, and we'll be here for another 12 months. Crazy to think that, if things work out, a year from now we'll be sorting through our things to take with us across the pond...
• Oh and on a related note, my best friend will be moving to Texas in 19 days - we're like, really growing up. It's weird!

• Today was the slowest day of all time. I only saw four patients all day. I did catch up on a lot of those little things I've been putting off...you know, like applying for next year's loans (no big deal or anything).

• Oh and guess what? My Step 2 CK is less than 3 months away...I think its time I start to mentally prepare myself for another 6 weeks of torturous studying. Honestly, I'm still not over the psychological anguish that Step 1 studying did to me! And what's worse - after my Step 2 CK I still have to worry about that PLAB exam (that I need to take before I can begin the Foundation Programme in the UK). I guess these stressors don't really ever end for doctors though, do they?

Radiation Oncology: Day 7-12

The past few days in the Radiation Oncology clinic have been a lot of fun. I have had the pleasure of meeting several survivors who were 5+, 8, 12 years out of treatment, some long term cures. "This man here" - points to the attending - "saved my life. I wouldn't be here today if not for him!" Seeing those patients inspires me in so many ways; to see what current patients are going through (physically as well as emotionally), it is absolutely humbling to see that some can make it out alive and well, with an admirable outlook on life and a satisfaction with living each day to its fullest. I love meeting these patients. They are amazing.

That being said, I have met many patients who are on our service for palliation. These patients are much more difficult to spend time with, for purely selfish reasons; it is incredibly difficult to attempt a trusting, understanding, and compassionate relationship with someone who may not be around next week/month. It can be emotionally draining. But these patients need a kind, compassionate, and dedicated physician at this time more than ever in their life. Roughly half of the patients on the service receive palliative radiation to attempt to alleviate pain or bothersome symptoms (such as confusion and personality changes due to brain mets). And radiation almost certainly provides good relief for these patients, which makes it very rewarding as a physician. 

I recently sat down and chatted with a very lovely young lady. She has these gorgeous, big brown eyes and a smile that lights up a room. She was wearing a cute outfit, complete with cute little flats and a color-coordinated hat to cover her hairless head. She had come up with an idea to cure cancer - to use what we have in nature to our advantage, exploit its natural ability to suppress cellular growth (she spoke about a specific plant). This theory certainly has some scientific backing, and could be a good avenue to pursue. After all, some of our oldest chemotherapeutic agents are derived directly from nature, such as the nitrogen mustard and vinca alkaloids. "Maybe this is why I got cancer," she said, "so that I could meet you and pass my idea on to you and your expertise." What a phenomenal attitude to have. Although I am sure that she has her difficult moments, when she can't seem to make the tears stop and searches for some reason why such bad things happen to good people, she does her best to remain optimistic, to keep hope alive. 

Last week, I went to a Cancer Fundraising Event with a bunch of girls from the clinic. It was so much fun, with such a good turnout. It raised around $30,000 for cancer patients from our area to use. The spotlight speaker was a young lady with Stage IV Lung Cancer with an amazing personality. She spoke of her struggles, her current battle, and about enjoying the little things in life, to cherish each moment. She talked about her Bucket List, and how each of us need to make one because, "after all, we're all terminal, really." I don't think there was a dry eye in the house by the end of her talk. What an inspiration. How beautiful to see so many people gathered together, donating their time and money to help find a cure for cancer.